RYDZ
RYDZ Vehicle Use Insurance Application
Prepared in partnership with Tucker Agency
Applicant & Business Information
Legal Business / Individual Name
DBA (if applicable)
Primary Contact Name
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Operations Information
Primary Operating Location(s)
Maximum Radius of Operations (miles)
Days / Hours of Operation
Describe operations and use of vehicles (routes, environments, passengers, events):
Vehicle Schedule
Vehicle Schedule
Rows
Unit #
Vehicle Description
VIN
Estimated Value ($)
Garaging Location
1
2
3
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RYDZ Vehicle Use Insurance Application
Prepared in partnership with Tucker Agency
Drivers & Safety Information
Primary Operator Name(s)
Minimum Operator Age
Driving Violations (last 5 years)
Safety Features
Safety Features
Speed Governor Installed
Passenger Restraints / Seatbelts
Formal Operator Training Program
Onboard Cameras Installed
Applicant Acknowledgement
I certify the information provided is accurate. Submission does not bind coverage.
Authorized Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: